0011-254 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my License.is in full force and effect.
License # Lic. Class Exp. Date
71d 88 R /3 ]fll3lJ?.0
ate �A '!,°Signature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I, am exempt from the Contractor's
License Law for the following reason:
( .) I, as owner of the property, or my employees with wages as their sole
compensation, will do the work, and the structure is not intended or offered for
sale (Sec. 7044, Business & Professionals Code).
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
() I am exempt under Section B&P.C. for this reason
Date Signature. of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of .perjury one of the following declarations'.
( ). I have and will maintain a certificate of consent to self -insure for workers'
compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
("y)' I have and will maintain workers' compensation insurance, as required by
Section 3700 of the Labor Code, for.the performance of the work for which this
permit is issued. My workers' 'compensation insurance carrier & policy no. are:
CarrierOLDEN EAGLE IN Policy No.
(This section need not be completed if the permit valuation is for $100.00 or less).
() I certify that in the performance of the work for which this permit is issued,
I shall not employ any person in any manner so as to become subject to.the
workers' compensation laws of California, and agree that if I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions. f
�Date:Z21-2(f Applicant ✓ s -" Z
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, iri
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to 'the conditions and restrictions set forth on . his -
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose,benefit work is performed under or pursuant to
any permit issued as a result of this applicator agrees to, & shall, indemnify
& hold harmless the_ City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of .issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
I correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes:
Signature (Owner/Agent) Date l�'�.-✓ j,_m�l.�
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 0011»2--&J. TRACT
!,�) bD 1s,MSa 7 287,19
JOB SITE
APN
ADDRESS
79 :570,UASIA
; 769-490 01412
OWNER
CONTRACTOR / DESIGNER /ENGINEER
lZRS CRO 1d.L pONNaJM`
{MURi tRO=L t OyWryLy
1535 30, 07 8"'1 ' a S, M 0200
1535 130. Illi E'IR111-47; UM 0200
SAA BERNAARDINO CA 92408
SAIX .MMMARDR40 ' CA. 92408
(909)381-6007 C-BLO 2120
USE OF PERMIT
MOLE FAIi31..Y: )WEA.: 0
LOT -1, PLAN 2A; SFD • PFI MIT i7iJn XOTINCLUDE aLOCK 'WA.LI-%
P00I40R I.RIclR3R1AYAf'PRO>t CH, P1,AX CHECK PER B.EDUCND13%FOR
A+ltll: TIP12 ISJ1. KNCE OF S"E 1A'lA14 TYP&
CUSTOM TOM CONS TR'UCTION 2.597 00 3F
PORCMPATIO 212.00 Sp
43ARAGFJC./ RPO -RT (�I( 11,958.00
�1�:�?1•+�'%C �!"�:�: C31ii'li�lg,!Ca'
I.ON rTRILICTION FE 1014100,418-000 $1.049,00
PLAN GH r1., X ,#+'EE 101-000-439-3 18 $211,66
MEC HANICM,FEE 191.00
I�i�'#�,Ci'.1ilCd�l.:f?'i" 1 C11-E10t?-+d 1C�l�Ltf1 $144.00
PIJMR[1G FEE $168,50
STRONG MOTION PLI - RL°.'3IO 101-000-241-000 $21.70
ORADINOF19 „ 1''11-000.423-000 $20.00
DEVELOPER IMPACT YZE $1,907.00
ARI' rN PUBLIC PLACID - WHE 7{11 -tai -255-01X1 9414
SUS -TOTAL COAl`.s" l-liill :'BION AND PLA9 Com,
T3,01.92
1.210 Pla PAifJ IS
$0.00
wE Now
DEC 12 2000•
_
.%,IT'Y Ut- LA
DATE
DA$LERECEIPT
d O
INSPECTOR
INSPECTION RECORD
OPERATION
DATE 7
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
..
Underground Ducts
Forms & Footings
�f
Ducts
Slab Grade
_/ Pj—p/
Return Air
Steel
Combustion Air
Roof Deck
O.K. to Wrap
_
oG
Exhaust Fans
F.A.U. .
Framing
_!Z _
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
_
Drywall - Int. Lath
0.1
r/j�
Final
Final
'�
POOL SPAS
BLOCKWALL PPROVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral
�
Lam"
Pool Cover
Sewer Connection
Gas Piping
Encapsulation
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
7 /
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
8
Final
-fir
Utility Notice (Perm)